CLINICALFINDINGSANDMANAGEMENTOFCHRONIC BLEPHARITISINA25-YEAROLDFEMALE-ACASEREPORT BY *OSAIYUWU, A.B.ANDEBEIGBE,J.A. DEPARTMENTOFOPTOMETRY,FACULTYOFLIFESCIENCES, UNIVERSITYOFBENIN,BENINCITY,NIGERIA. EMAIL:[email protected] *Correspondingauthor ABSTRACT Blepharitisisaninflammationoftheeyelidmarginswhichsometimesleadstosecondarychangesinthe conjunctivaandcornea.Symptomsofblepharitistendtobelongstanding,thus,blepharitisismoreofa chronicconditionthanbeingacuteandbotheyesareusuallyaffected,however,thesymptomscaneasily beeased.Oncesymptomshaveeased,daily'eyelidhygiene'canusuallykeepthesymptomstoaminimum. Visionisrarelyaffected.Thiscasereportreviewedthemanagementofblepharitisina25-yearoldgirlthe clinicalfindingsandtreatmentoptionswerealsodiscussed. KEYWORDS: Blepharitis,Madarosis,Conjunctivitis,Keratitis,.Staphylococcusauerus Received03/03/2010Accepted04/06/2010 INTRODUCTION (OTC)drugsofwhichshecouldonlyremember Historically,blepharitishasbeendividedinto chloramphenicoleyedropasoneofthedrugs anteriorforms(affectingtheanteriorlidmargin applied.Thepatienthadneverhadaneye andeyelashes)andposteriorforms(affectingthe examinationpriortohervisittoourclinic.The meibomianglands)1,2.Blepharitisisoneofthe patientalsocomplainedthatthesymptomsoften mostcommoneyeliddisordersoftenassociated 'comeandgo'andthatoccasionallythesymptoms withtearfilmdisruptionandaccompanying weresoverysevereandtherewerealsolong symptomsofwhichthemainstayofmanagementis periodswithoutanysymptoms.Thepatient's meticulouslidhygienenotmedicinal3.Itismore medicalandfamilyhistorywasnegative. commoninyoungfemales4.Oneofthemost accompanyingsymptomsismadarosisofwhich CLINICALFINDINGS infectionduetoStaphylococcusaureus isoneof HerunaidedvisualacuityatdistancewasOD thecauses.Long-standingstaphylococcal 6/6,OS6/6andOU6/5+,whileherunaidedvisual infectionisassociatedwithmadarosis,whitening acuityatnear(0.4m)forODandOSwasN5. (poliosis)andmisdirection(trichiasis)of 5 Colourvisiontestingwithpseudoisochromatic eyelashes.Blepharitisischaracterizedby plateswasnormalOU. inflammationoftheeyelidmargins.Itmaycause Pupilswereequallyroundandreactivetolight, rednessoftheeyes,itchingandirritationofthe eyelidsinoneorbotheyes.Itsappearanceisoften noafferentpupildefectwasnotedOU. confusedwithconjunctivitisandduetoits ConfrontationfieldswerefulltofingercountOU. recurringnature;itisthemostcommoncauseof Extraocularmuscleswereunrestrictedinallgazes 'recurrentconjunctivitis'inolderpeople.Itisalso andthealternatecovertestdemonstratedboth oftenmistakenfor'dryeye'bypatientsduetothe orthophoriaatdistanceandnear. grittysensationthatmayoccur. Botheyeslookedgenerallyunhealthyin appearance;theeyelidswereinflamedandsore CASEREPORT withtheeyeshavingsomedischarge,irregularity A25-yearoldfemalepatient,IUpresentedto andulcerationofthelidmarginsandmadarosisand ourOptometryClinicon30April2008witha therewasimproperlidclosurewhenthepatient historyofirritationinbotheyessincethepast eighteenmonths.Shereportedthattheproblem wasinstructedtoclosetheeyes. startedmildlywithoccasionaldischargeand Slitlampexaminationrevealedthefollowing: itching,butprogressedtoamorecopious Lashes:lossoflashes(madarosis),scantyand discharge,itching,rednessandalmostacomplete misdirectionoflashes(trichiasis)andcrustingof lossofeyelashes(madarosis).Shealsoreported lashes. thatsheappliedacoupleofover-the-counter Themeibomianorifices:crustingandplugging. JNOA-VOL16,2010 26 PDF created with pdfFactory Pro trial version www.pdffactory.com Theconjunctiva:papillaryinjection. -Thefewmisdirectedlasheswereepilated Cornealfindings:punctateepithelialerosions, afterinstillationoftwodropsof0.05% marginalinfiltrates,pannusandphlyctenule novesine. formation. -Tab.Vit.C,2tabstdsfor2weekswasalso prescribed. DirectOphthalmoscopy:noabnormality;both crystallinelensesweretransparent,therewere Thepatientwasagainremindedtobedrug normalopticnerveswithacup-to-discratioof compliantandtoreturnin2weekstimeforfollow 0.3/0.3OU,neuroretinalrimswerehealthy,retinal up. vesselswerenormalwithanarterio-venousratioof 2/3OUandbotheyespresentedwithnormal FOLLOWUP#2 macularfindings. Thepatientreturnedforfollowupon19May 2008.Hervisualacuitiesremainedthesameand Diagnosis:Chronicblepharitis shereportedthatshehadbeendrugcompliant.The IUwascounseledandinstructedtogoforaswab generalappearanceoftheeyeslookedimproved testandwasscheduledtobeseenon5May2008. whencomparedtoherfirstvisit. Slitlampexaminationwasconductedonher FOLLOWUP#1 andfindingswereaslisted; IUreturnedon5May2008toreviewtheswab Absenceofmisdirectedlashes result.Theswabresultrevealedthecausative Therewasreducedcrustingofthelashes organismasStaphylococcusaureus. Hervisual Therewasamarkedreductionofcrustingand acuityremainedstablewithunaidedacuitiesof6/6 pluggingonthemeibomianorifices ODandOSand6/5+ OU.Schirmertestwascarried Therewasalmostatotalabsenceof outonthepatientandtheresultwasquite conjunctivalpapillaryinjection. favourable. Thecorneastillpresentedwithsomepunctate IUwascounseledonthetreatmentregimen epithelialerosions,afewmarginalinfiltratesand thatwouldbegivenandthatastrictcompliance thepannuswasresolvingquietlyaswellasthe wasallthatwouldbeneededforaneffective phlyctenules. treatment.Shewasalsomadetorealizethatthe Directophthalmoscopyrevealedno treatmentmayspanthroughmonthsandthusshe abnormality. hastolearntobepatient.Shewasinstructedto Thepatientwasencouragedtokeepupwiththe carryoutthetreatmentthus: complianceastheprognosiswasgood.Her Firstly,theapplicationofheattowarmthe medicationswerereviewedandshewasadvised eyelidglandsecretionsandtopromote thus: evacuationandcleansingofthesecretory passages. Take:Cap.Doxycycline100mgforanother2 Secondly,theeyelidmarginshouldbewashed weeks mechanicallytoremoveadherentmaterials GuttBlephamide1dropbidfor2weeks suchascollarettesandcrustsandtocleanthe Oint.Erythromycin(0.5%)qidfor2weeks glandorifices,wateroftenisused.Gentle Tab.Vit.C2tabstdsfor2weeks mechanicalscrubbingoftheeyelidmarginis allthatisneeded,vigorousscrubbingisnot Patientwascounseledtocontinuecleaningthe necessaryandmaybeharmful. lidsasinstructedandgenerallymaintainavery Thirdly,themedicationsshouldbeappliedto goodhygiene.IUwastoldtoreportagaintothe theeyelidmarginafterithasbeensoakedand clinicinanother2weekstimeforfollowup. scrubbed. FOLLOWUP#3 Thepatientwasplacedon IUreturnedforfollowupon2June2008.Her -Cap.Doxycycline200mgstat,then100mgfor visionwasunchangedandtheeyeslookedquite 2weeks. healthy.Thepatientsaidthatshewashappywith -OintmentErythromycin(0.5%),0.5inch thedrasticimprovementofhereyes.Slitlamp ribbontobeappliedtolidmarginqidfor2 examinationrevealedabsenceofmisdirected weeks. lashes,afewcrustsonthelashes,afewcrustsand -Sulfacetamidesodiumandprednisolone absenceofpluggingonthemeibomianorifices, acetate(Blephamide;10%sulfacetamide; absenceofconjunctivalpapillaryinjection,pannus 0.2%prednisolone),1dropqidfor2weeks. andphlyctenuleshadcompletelyresolvedbutthe 27 JNOA-VOL16,2010 PDF created with pdfFactory Pro trial version www.pdffactory.com corneastillpresentedwithafewpunctateepithelial patientswithchronicblepharitisinclude erosionsandmarginalinfiltrates. Staphylococcalepidermidis, Propionibacterium Thepatientwascommendedfornotonlybeing acnes,corynebacteriaand Staphylococcus drugcompliantbutalsoinmaintaininggoodlid aureus.6,7.Astaphylococcalinfectionnormally hygiene.Hermedicationswerereviewedthus: presentspredominantlyinyoungwomento middle-agedwomen4.Collarettesorcuffsoffibrin Take:Cap.Doxycycline100mgforanother2 (matted,hardscales)extendfromthebaseofand weeks alonglashesasasleeve.Eyelidulcerationsarefine GuttBlephamide1dropdailyfor2weeks atthebaseoflashes.Thereisalsotheabsenceof Oint.Erythromycin(0.5%)tdsfor2weeks eyelashesinstaphylococcalinfection;this Tab.Vit.C2tabstdsfor2weeks. conditionisveryrareinseborrheicinfection. Themanagementofblepharitisisaprocess Thepatientwastoldtocomeforfollowupin whichmustbecarriedoutforprolongedperiodsof another2weekstimewhenwehopedtheeyes time,implyingthatevenwhensymptomshave wouldbefitenoughtoundergothetestfor subsided,thetreatmentshouldstillcontinuebutat refraction. reduceddoses.Prognosisisusuallygoodwhenthe patientiscomplianttotheinstructionsgivenasper FOLLOWUP#4 3 IUreturnedtotheclinicon16June2008.Her maintenanceofproperlidhygiene.Thepatientin visionwasunchangedandhereyeswerelooking thisreportwasverycompliantanditreflectedin reallyhealthy.Slitlampexaminationrevealedno theprognosisreport. abnormalityandtherewasalsonoabnormality Conjunctivitisandkeratitiscanresultasa detectedonophthalmoscopy. complicationofblepharitisandrequiresadditional IUwassoverygratefulbutshewantedtoknow treatmentbesideseyelidmargintherapy. ifshewouldgrowthelashesagain.Shewas Antibiotic-corticosteroidsolutioncangreatly reassuredthatthelasheswouldre-growbutthatit reduceinflammationandsymptomsof wasnotgoingtobespontaneous.Wealso conjunctivitis.Cornealinfiltratescanbetreated 1 counseledIUaboutreferringhertoan withantibiotic-corticosteroiddrops.Small ophthalmologisttocarryoutlidrepairs,butshe marginalcornealulcerscanbetreatedempirically, wasnotsoenthusiasticaboutitandsherejectedthe butlargerparacentralulcersshouldbescrapedand ideaofthereferral.Wealsomadehertorealizethat specimenssentfordiagnosticslidesandforculture 4 thetreatmenthadnotendedmeaningthatshe andsensitivitytesting. shouldstillcontinuewiththelidhygiene Overalltheprognosisforpatientswith religiously.Wereviewedhermedicationby blepharitisisgoodtoexcellent.Patientswith placingheronthedoxycycline,100mgdailyfor unilateralorveryasymmetricblepharitismayhave thenext2weeks;shewastostopinstillingthe sebaceouscellcarcinoma.Anoculoplasticsconsult 4,7 blephamidebuttocontinuewiththeointment